<!-- INCLUDE overall_header.html -->
<div class="panel"  width="70%">
   <div class="inner"  width="70%"><span class="corners-top"  width="70%"><span></span></span>

   <div class="post"  width="70%">
      <p>
<table width ="100%" align="center">
<form name="postform" action="{S_POST_ACTION}" method="post" name="postform"{S_FORM_ENCTYPE}>
<tr>
<center><h3>{L_APPLY_TITLE}</h3></center>
</tr>
</table>
<table width ="100%" align="center">
<!-- IF ERROR -->

		<center><span class="genmed1 error">{ERROR}</span></center><br>

<!-- ENDIF -->
<b><center>{L_APPLY_INFO}{APPLY_REALM}.</center></b><br>

<!-- BEGIN template -->
<tr>
	<td class="row1" width="20%"><b class="genmed1">{template.QUESTION}{template.MANDATORY}:</b></td>
	<td class="row2" width="50%">{template.TYPE}</td>
	<td rowspan="8" class="row2" width="30%"><b class="genmed1"></td>
</tr>
<!-- END template -->

</table>
 <center>     <!-- IF S_CONFIRM_CODE --><br>
      <dl>
         <dt><label for="confirm_code">{L_CONFIRM_CODE}:</label><br /><span>{L_CONFIRM_CODE_EXPLAIN}</span></dt>
            <dd><input type="hidden" name="confirm_id" value="{CONFIRM_ID}" />{CONFIRM_IMAGE}</dd>
            <dd><input type="text" name="confirm_code" id="confirm_code" size="8" maxlength="8" tabindex="21" class="inputbox narrow" title="{L_CONFIRM_CODE}" /></dd>
      </dl>
     <br> <!-- ENDIF --> </center>
<table width ="100%" align="center">
<tr>
<!--<td class="cat" width="20%"><b class="genmed1"></b></td>-->
</br>
<td class="cat" align="center" width="100%"><font size="2"><input class="button1" type="submit" accesskey="s" tabindex="23" name="post" value="{L_SUBMIT}" />
</td>
</tr>
</form>
</table>
      </p>
   </div>

   <span class="corners-bottom"><span></span></span></div>
</div>


<!-- INCLUDE overall_footer.html -->
